Volume 27: Aging

Volume 27 – Aging The Western world is heading towards a life expectancy of 100 years or more, and other parts of the world are soon to follow. Visions of a con­tinent full of geriatric hospitals and nursing homes come to mind. Cur­rent­ly the West is in a phase of ‘age accept­ance’.

The better half of the older popula­ tion has to be reinte­grated into society, and be reconnected with production to allow for the (continued) care of the other half. In fashion, so­cial con­ tracts and physical perfor­mance, the strict distinction between age groups is disappearing – blending ‘new’ and ‘old’. But another perspec­tive looms on the horizon: doing away with aging altogether. Medical and material research is heading in the di­rection of solving deterioration. Per­haps it’s just another take on the sus­tainability revolution. Next to accepting and dealing with aging, fighting it intro­ duces a new set of challenges.

Contents 2

Editorial

Arjen Oosterman

4

The Longevity Revolution and Other Tales of Aging

Deane Simpson

6

An Age-old Problem

Timothy Moore

8

Pyramids

Martti Kalliala

12

Mediating the Brief

Erhard An-He Kinzelbach

14

Nursing Home Hainburg

Architecture Christian Kronaus + Erhard An-He Kinzelbach

18

A Manifesto for New Aging

Matthias Hollwich

19

An Architect in the Gray Zone

Matthias Hollwich interview

24

The Coming of Age

AA Bronson interview

28

Aging in Place – New York’s Captive Population

C-Lab

42

Counting Stoops

Michael Gusmano interview

45

In the Long Run – Design Thinking in Finland

Bryan Boyer

48

Outside Our Comfort Zone

Indy Johar

49

Trust Design – Part One: Trust, Design and Aging

Insert

89

Cities as Software

Marcus Westbury

92

Design Age

Jeremy Myerson interview

95

Merging Old and New

Paul Meurs interview

38

Hibernation

Sander van Wettum

110 One Billion AD

Geoff Manaugh

114 Bio-technical Arrangements of the Aged Body

Deane Simpson

116 The Persistence of the Iranian Bazaar

Azadeh Mashayekhi and Negar Sanaan Bensi

124 The Villages of Florida

Deane Simpson

138 Wheels

Deane Simpson

144 Reconstruction: Dream or Trauma

Joos van den Dool

150 Construction Materials Lifespan in Years

AMO

152 Stealth Care

Arons & Gelauff interview

155 Care Cluster and Senior Housing

Architecture Arons en Gelauff

158 Santa Rita Geriatric Center

Architecture Manuel Ocaña

162 Housing for Elderly People Alcácer do Sal Volume 27

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Architecture Aires Mateus

167 Turn-key Home/Two in One, Puttershoek

Katarina Seda

174 It’s Too Late!

Supersudaca

184 Colophon 184 Corrections/Additions

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Arjen Oosterman

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Volume 27

Fight and Ac cept

When the credit crisis hit hard in 2007, the common reaction was one of sheer amazement. It was fascinating to see billions and trillions of dollars evaporate at such speed. Despite expert warnings that things would never be the same, the general expectation was that normality would soon be restored. In our spectacle society, we are used to the excitement of sudden change. We respond to these events like we’re watching a magician. First, he shows that everything you see is ordinary, everyday, that there are no tricks involved. Next, he stuns his audience with the unimaginable, and while the public is still struggling with excitement and a deeply felt anxiety, he restores the order of normality – look, nothing has changed. This is the understanding of reality we prefer: nice show, lights on, back to business.

There is another model of reality active in the understanding of our own situation: the managerial one.

A problem arises like regional population shrinkage, sea level rise – that sort of thing. It has to be addressed and solved; someone has to do it, but it’s not my concern.

Cannot the government or the municipality take this on?

I pay my taxes, don’t I? And it’s beyond my reach anyhow.

In a peculiar way, both models make for a nice, stable world, at least on a personal level. They are two cornerstones of the bourgeois belief system that keeps things going. Tomorrow won’t be that different from today. Like minor ailments, disruptions (even major ones) will spontaneously go away or can be treated.

But what about aging? As one of the essences of living, it has always been a part of life. There’s no use denying it, and there is certainly no escape from it. But on the scale of society, major changes are happening with respect to age. After the doubling of human life expect­ ancy in the last century, this century will see another major increase. In combination with the dramatic increase of the 65-plus part of the population compared with the popu­lation as a whole, this challenges our own expec­ tations and obligations as it threatens social models we’d grown accustomed to. So where is the magician and where is the manager?

Well, the magician is at the doorstep. She’s now called doctor and biomedical researcher. Her trick of ‘Now you’re young – now you’re old (scary!) – now you’re young again’ is mainly one of appearance, but a more fundamental meddling with the body is looming on the horizon. Instead of replacing defunct body parts in a mechanical way (with the doctor as mechanic and the body as machine), other approaches are being tested. Growing tissue and eventually complete organs is one such method. Another is switching off the aging mechanisms in cells on a genetic level. A third one, that promises results within the decade, focuses on preventing damage on the cellular level. The random assaults in our biochemical body produce deterioration and failure of functions in time. By eliminating these assaults, the body can continue to perform properly during old age.

Basically, these developments focus on the elimination of aging as a phenomenon. After the agricultural and industrial revolutions, fighting aging promises to be the next revolution in the making.

The social and spatial implications of these devel­ op­ments are hard to imagine, but before it becomes a reality, there is some time for reflection. In the meantime, we’re in the middle of transformative shifts (with the amount and intensity of care needed compared with the number of working people) and it is here that the manager appears on the stage. After the Second World War,

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Western Europe turned to building the welfare state: a lifelong, guaranteed, material minimum for everybody.

It came with retirement, a state pension, and taxes of course. The model was (and still is) based on inter­gen­er­ ational solidarity. The working population pays for the care of its parents and grandparents. It is not unlike in traditional societies where children take care of their older family members, but now it acts on the level of society as a whole. This social arrangement came with a price: the working part of the population should not be held back in any way to contribute to production. So elderly care facilities were invented to free the family unit from their traditional obligations. Economizing labor under the guise of retained independence (parents not moving in with their adult children) was the model; alienating and segregating a part of the population was the result. Old age as a problem, a social burden really, was to be managed and solved (from the production perspective). In the Netherlands and surrounding coun­ tries, the (financial) limits of this arrangement became apparent during the 1960s and 70s when the number of retirement homes (and costs) grew explosively. In the mid-80s, a drastic change in policy was set in motion.

Instead of providing a room for every citizen of 65 and older, the policy was now (and still is) focused on keep­ ing people away from institutions and in their own homes for as long as possible. A whole set of intermediary care facilities and typologies were introduced. The next target was retirement itself. The analytical model of learning phase, working phase and retirement phase in modern society had to be replaced by a more continuous and inclusive model: a reconnection of the older popu­ lation with production (where possible) and reintegration in society at large. Acceptance is the buzzword here.

We’re in the middle of that transition.

This paradigm shift comes with all kinds of trans­ formations. Instead of moving from one home to the next depending on one’s personal situation (alone, family, empty nester, retired, care dependent), the emphasis is now on single environments that allow for all of these realities consecutively. It is another take on sustainability from a social point of view. Since buildings do not tend to expand or shrink, this asks for other types of flexi­bi­ lity. This goes for cities too, where shifts in composition of its population (age groups and income classes) change the economic and social realities.

Another challenge that society faces is care for the rapidly growing number of elderly with dementia, multiple physical impairments and handicaps. The nurs­ing home is the current default institution, but this hospitallike end station is the horror scenario for every­one that still has their wits. It is fascinating that a typology that deals with total control has received so little attention from architects. Improvements within the walls of the institution are very well possible, but maybe we should design a whole new architecture of care for this category in society as long as the magician hasn’t perfected his trick.

The reintegration of old and young is not only con­ fined to the physical performance of the human being.

A more integral look at an aging society is gradually surfacing. For instance, preservation has transformed from a dedicated field of expertise into an integral take on the existing environment and how to adjust it to our needs. In design, a less one-dimensional and dogmatic focus on ‘forever young’ is discernible as the growing market of elderly consumers asks for adjusted marketing

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strategies. After the age of the ‘new’, an era of integra­ tion is at hand. It comes with the blurring of boundaries between social roles, age groups and cultures with blurring as a strategy to work on integration, blurring as a way to lead a richer life.

With major structural shifts occurring due to the aging of society, there comes a changing position and role of design and architecture. The realm of invention is still available and needed, but also and quite urgently, a reconsideration of collectively individualized ambitions and goals. The modernist dogma was con­ cerned with the provision of material quantity; the post­ modern mantra was individualized expression. Now, the challenge is to locate other fundamental values (like trust, which is ex­plored within the Trust Design insert found in this issue). Till death do us part, but until that moment, we’re in it together.

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The Longevit y Revolution and Other Ta les of Aging

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31/03/11 15:50

An Age-old P roblem Timothy Moore 2010

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Average life expectancy Median age

Volume 27

After a century of celebrating the young, fresh and new, the twenty-first century will be evermore mature.

Over the last fifty years, the global life expect­ancy at birth has increased by over twenty years. This dra­matic increase in longevity, paired with a declining fertility rate, will continue in the next thirty years to see the world’s elderly population (people over 60) doubling to two billion (an increase from one-in-nine to one-in-five people). The median will reach a middle-age of 37.8 years.

With the form of the population pyr­a­mid morphing from a stepped terrace to a sky­ scraper-like shape between 2010 and 2050, it emphasizes that not only are we living longer, but our society is getting older. A decline in youth presents a series of societal changes: an extension in labor parti­cipation over time, a mutation in multi-generational family forms, and the increasing compet­ itiveness of global migra­tion (due to tight do­mes­tic labor markets).

While many countries are currently prepar­ ing for the challenge of aging, Europe has already aged: the number of dependents over 65 was larger than the number of de­ pendents under 5 in the mid-70s. Fol­low­ing in their footsteps, the booming economies of Brazil, China, India and the Gulf states will undergo a demographic transition to match the European trend of mortality and fertility rates in the near future. While they should have the economies to provide for it, in other less developed countries where many of the two billion geron­tocrats will live, poverty and the lack of basic health­ care provisions is a key challenge to a happy, long life.

The aging of society provides a new capacity to cap­ture wisdom and ex­pe­rience despite the drain it may in­flict on resources. The irony to the policy-makers facing these chal­ lenges is that they will be around in thirty years time to face the long-term de­ci­sions that they have created. With the flattening of the popu­lation pyr­a­mid in the im­pending future, the diagram is clear: the time is now to wrinkle out the issue.

More-developed Less-developed

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North America Middle East

Sub-Saharan Africa Western Europe

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male life expectancy age 0

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World More developed Less developed North Africa SubSaharan Africa Middle East Asia Oceania North America South America and the Carribean Western Europe Eastern Europe Average life expectancy

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Median age

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More-developed Less-developed

North America Middle East

Sub-Saharan Africa Western Europe

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Martti Kalliala

As average life expectancy dramat­ ically increases, what will it be like if there is no upper limit to this growth?

What happens when we strive to live forever?

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Volume 27

Pyram ids

A population pyramid is a graph describing the dis­tri­ bution of different age groups among a group of people.

Children reside at the bottom, the elderly at the top.

Historically, the term ‘pyramid’ has been an apt architec­ tural reference as most populations tended to plot out a triangular silhouette: both fertility and death rates were high and only a lucky few reached the pinnacle of old age. The world at large was a place of the young. Today, however, it is only the most impoverished societies that still live in the youthful but ruthless age of pyramids.

For it is a phenomenon that has now been going on for the best part of a century: when nations develop from pre-industrial to industrial, both birth and death rates begin to decrease. The occurrence of this demographic transition is systematic and universal – without notable reversals to be found.1 The industrialized world is be­com­ ing fewer and growing older. The last bulge of youngsters, the baby-boom generation that used to form the fat bottom of our population pyramids, is moving upward.

The pyramid is, if not turning on its head, forming a wholly new top-heavy silhouette. To say birth and death rates are falling, however, is not to say people wouldn’t eventually be dying – thus far we are – nor does it mean couples wouldn’t be having children – the vast majority of them do. It’s just that they have too few.

Now, we have become acutely aware of the ca­lam­ itous effects simultaneously graying and shrinking demo­ graphics are bringing about on our welfare systems.

The coming pension meltdown will hit us with unseen severity. Yet what our birthrates suggest is something even more worthy of attention: the end of the regime of growth. For it will be the first time in human history that the constraint for economic activity will not be the ability to feed or the depletion of a resource, but our own collective lack of desire to produce new people.2 We are hooked on growth – a reasonable addiction – as it was promised to be perpetual and boundless. Yet now it turns out much of the growth experienced thus far has lent itself to transitional population dynamics that has, by and large, benefited affluent nations – and laid a huge disadvantage on the rest. And that is not to speak of the wealth built on the natural and human resources ruthlessly seized from the rest of the world. Now this pace can not be sustained anymore. We are becoming old, slow and few; the emerging economies young, many and hungry. What the situation will inevitably call for is a global re-balancing act, a new economic equilibrium.

By many this will be seen as an ultimately positive phenomenon. Sure, pensions will cause an immense, although temporary challenge, but less consumers with Western material standards would result in less pollution, less exploitation of natural resources and less of de­ struc­tive human activity in general. It is also primarily nations with a youth bulge in their population pyramid that experience turmoil. While adopting lowered material expectations, the graying developed world could settle into their own Pax Geriatria3 and begin to devise a new non-financial criterion for wealth.4 But this is unlikely. A future of de-growth has proven to be an unacceptable notion and opposed by all means possible. As a top-down enforced aphrodisiac has not been found – not to say it wouldn’t be now some 30 years late – a number of other measures are being put forth.

All equally unsustainable.

The most often propagated and employed panacea is that of ambiguous ‘reform’. But what else does the term mean today than social regression? A word that

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once was associated with progress has come to mean nothing else than ‘less regulation of corporations, lower wages, fewer rights for workers, and weaker unions, i.e. the elimination of anything that can impede corpora­ tions’.5 And they surely can not go the necessary lengths without causing civil unrest. The geriatric peace would not suffice. Immigration offers no easy way out either, for without doubt it is not in the interest of the most im­pov­er­ished nations among us to be seizing their prime labor force in the tens of millions – not to speak of the xenophobia cultivated by the populist right, expected to grow courtesy of the anxiety for the new that is asso­ci­ ated with aging. We could increase efficiency – a popular solution. But even if the rise of productivity could be principally targeted towards the underutilized worker pool of senior citizens, the contraction of the labor market will be so vast that an equiproportional increase in pro­ ductivity would require technical advances of miraculous traits – a geriatric Wirtschaftswunder.

In the wake of the detonation of the pension bomb, claims are being made of paradigm shifting advance­ ments in the medical deceleration of the aging process.

This offers a thrilling proposition: if we can not feed the labor market through increased birth rates, we might as well do it by extending our own healthy existence.

A mere seven year offset of aging would half the rates of cancer, diabetes, Alzheimer’s and heart disease,6 re­leas­ing enormous financial resources to be used else­ where. This is what S. Jay Olshansky and his colleagues have coined the ‘longevity dividend’: instead of living longer we ought to live healthier and garner its benefits.

Yet essentially the relatively modest delaying of aging is nothing else than an incremental improvement in the efficiency of the human apparatus. To be able to meet the requirement of constant growth, we would need to live healthy ever longer; that is, make the period of seemingly inevitable frailty, disability and elderly de­ pendency proportionately smaller and smaller com­pared to our productive years. Seven years of extra health becomes ‘only’ a fix for the pension crisis. Even if we manage to delay the start of aging, at some point we still become physically aged, need care and, even­tu­ally, die.

So why stop here?

A number of scientists go much further in their claims than Olshansky et al. In fact, an international bio­ medical war on aging is raging in laboratories and con­ fer­ences around the world. In tandem with Ray Kurzweil, who believes aging will be eradicated by the end of the century, the widely disputed gerontology theoretician Aubrey de Grey has declared he expects a significant number of people alive today to become actual millen­ni­ als. What De Grey and his SENS foundation are working towards is a condition coined Negligible Senescence, where the biological process of aging is eliminated, post­ poning it to indefinitely greater ages so that it will never be reached.7 An individual that has undergone the neces­ sary treatments would essentially be mortal only through accidents and violence posed from the outside, or the few malignant diseases left uncured. As the occurrence of fatal accidents and acts of random violence in the de­ veloped world is rather low, the average life-expectancy of a quasi-immortal would be around a thousand years.

For the cautious, much longer.

Now, given the unsustainability and virtual futility of any other solution, the only practicable avenue any declining industrial nation unwilling to step off growth can take, is that of becoming a society of negligible

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se­nes­cence. For death rates in such societies do not increase with age as they do in senescent organisms; their popu­la­tion pyramid is an unwavering tower.

All growth accu­mu­lates: personal wealth, knowledge, power. A nation of vir­tu­al immortals would become a land of terrestrial demigods.

But what a strange land that would be, as immor­ tal­ity does not come without a cost. Children would slowly be­come as rare a phenomenon as say, albinism is today. Pre­suming that birthrates would continue their decline, sis­ters, brothers, cousins, aunts and uncles would slowly become extinct; the idea of a biological contemporary, alien.

What about the subjective notion of time? Earlier, long-term responsibility for the common natural realm was administered through myths and animist beliefs.

Today we endeavor to feel responsibility for the world by peeking through the eyes of our speculative grand­ children. The single most valuable contribution of the eradication of senescence could be to the notion of sus­ tainability: it wouldn’t need to be guided anymore through forced inter-generational solidarity, but a primordial worry for our own future well-being.

In order for extreme longevity to be rendered a national competitive edge, it needs to be scarce; not within a nation but between nations. Its price will keep it a privilege of the developed world as, judging from the dealings of the pharmaceutical industry of today, there is no reason to suspect there would be any other than profit-oriented motives in making the longevity treat­ments affordable. Already certain cancer medications are priced not based on the costs of their development or manu­ facturing, but their proven ability to extend life. In other words: their price is the market value of life – currently going at 100,000 dollars per year.8 However, cancer medication is a niche product where­as the potential clientele for longevity treatments is measured in the hundreds of millions, if not billions.

With­out a doubt, at the onset when they enter the market, their price will be very high even for denizens of indus­ tri­alized nations, making them available only to the most af­fl u­ent faction of society. Given the risk of creating an op­u­lent minority class of immortals is not in the interest of a society willing to reap its benefits at large. Although it might be inevitable that early-adapters will be primarily citizens of wealth, it is necessary to make the treat­ments as quickly as possible available to the large masses. If re­ducing their price even through government subsidies proves to be impossible, a state could issue them to a re­stricted amount of citizens until they become more widely affordable. The only just method of choosing the ones to be treated is that of lottery, although depending on the country’s characteristics, other practices could be employed.

But what about those individuals who wish to remain au naturelle? Is their significantly smaller contribution as a productive member of society to be sanctioned?

If aging is voluntary, will pensions or publicly provided care for the elderly cease to exist? The organization of a welfare state is structured around the assumption that each citizen contributes his or her share in the form of labor and/or taxes to the best of their abilities, while in turn enjoying its services in times of dependency. How ought this formula be restructured in a world that is not only hooked on growth but is growing growth itself; where those who decide to remain ‘natural’ contribute less while simultaneously requiring more?

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170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Rapid Growth Sudan 2009

Negative Growth Finland 2010

Negligible Senescence Sweden 2105*

Number 1 Burj Khalifa 2011

Volume 27

* Population pyramid of Sweden projected for year 2105, when 10 percent of the population accepts interventions leading to ‘negligible senescence’ as developed by Leonid A. Gavrilov and Natalia S. Gavrilova, 2010

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Reasons to refuse treatments will vary from reli­ gious to economic to social. If one is unlucky to be born without, say, any social intelligence, will the decision not to undergo centuries of awkwardness and essentially unhappy life be considered passive suicide – an act pe­ nalized today. Not to speak of the disabled, par­tic­u­larly those incapable of making or communicating the decision for themselves. And without anti-socials, physically or mentally disabled, and other hapless members of society, what sort of (in)voluntary eugenics are we embarking on? Admittedly, there is something unsavory in the prophesied near future inhabited in visions put forward by the longevity enthusiast community, by a small group of affluent early-adaptors: 200 year-old wakeboarding venture capitalists on extended sabbaticals, living out every youthful dream left unlived during their actual adolescence. For suddenly, the wakeboarder has much more to lose than his natural third-world counterpart: what is some 50 years of subsistence compared to virtual eternity in affluence?

In a similar fashion than the shape of its population pyramid, the manner in which a society builds is illus­ trative of the phase of development it is going through.

A compulsion for pure physical height is never expe­ri­ enced without concurrent rapid economic growth. Early twentieth century New York and Chicago, the rise of the East Asian Tigers in the 1990s, China’s turbo-fueled adoption of state capitalism and the Gulf region’s rein­ vention of itself as a ‘destination’, all cemented the height of their rise in the form of skylines composed with clus­ ters of phallic architectural gestures. For most, the value of height is indirect; it is the multiplication of floor plates accommodating profit-generating rentable square meters that counts (unlike a population pyramid: each of its levels is more valuable than the one below). Yet for others, height itself is a means to an end. Securing the fleeting status of number one, home of the tallest, is modernity’s protocol for establishing the emergence of a location of global influence.

But building towers takes time. Initiated in 2004 at the height of Dubai’s upsurge, the Burj Khalifa, with its height of 828 meters and 160-plus floors, opened six years later as the tallest building on Earth amidst abandoned construction sites.

Now, towers are signifiers of growth. But in a state with no aging, the population pyramid itself becomes growth, and as some kind of ironic jest: the race to the heavens is replaced by a demographic competition of staying as long as possible from heaven. The population pyramid becomes a status symbol – the tallest, an icon; its height and girth subject to envy and admiration. And as non-senescent populations strive on accumulation, each level becomes more valuable than the one below.

The pyramids must be remodeled, the Tower of Babel will not be mentioned.

In the end, it is a simple outlook: if we do not believe in the possibility of a yet-to-be-established postgrowth world order, and few seem to do, it is only a race to the pinnacle that will let us sustain. However, if we do, may senility do us well:

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any more from life than wisdom – the wisdom of those who have seen a great deal without forget­ ting, who look at each thing as if for the first time.

– Franco Berardi Bifo, Exhaustion and Senile Utopia of the Coming European Insurrection

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dward Hugh, ‘Of Population Pyramids and Value Chains’, E September 18, 2006. At http://fistfulofeuros.net/afoe/ of-population-pyramids-and-value-chains.

Edward Hugh, ‘Japan’s Population Challenge’, August 23, 2005. At http://fistfulofeuros.net/afoe/japans-populationchallenge.

Mark L. Haas, ‘A Geriatric Peace?’, International Security 32, 2007, pp. 112–147.

Franco Berardi Bifo, ‘Exhaustion and Senile Utopia of the Coming European Insurrection’, e-flux journal 21, December 2010.

Laurence Parisot as quoted in ‘Why Reform Has Become a Dirty Word?’, September 8, 2006. At http://fistfulofeuros. net/afoe/why-reform-has-become-a-dirty-word.

S. Jay Olshansky, et al., ‘In Pursuit of the Longevity Dividend’, The Scientist 20, March 2006, pp. 20–36.

Aubrey De Gray, Ending Aging: The Rejuvenation Break­ throughs that Could Reverse Human Aging in Our Lifetime (New York City: St. Martin’s Press 2007).

Bevacizumab, sold under the trade name Avastin, produced

by Genentech/Roche.

i n a different scenario – one that we should anticipate at the cultural level – the process of senilization may open the way to a cultural revolution based on the force of exhaustion, of facing the inevitable with grace, discovering the sensuous slowness of those who do not expect

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Erhard An-He Kinzelbach

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Volume 27

Mediat ing the Brief

Where do we want to live when we are old? In times of an aging society, it is far from surprising that one of the architectural typologies with the largest growth rates is retirement housing. There are, roughly speaking, three different categories of retirement housing, each catering towards different degrees of frailty and impairment: inde­pendent living, assisted living, and skilled nursing facilities, which are commonly known as nursing homes.

When growing old, everybody will certainly want to stay at his or her home for as long as possible. Many people fear to move into a care institution as an inpatient – an environment often perceived to be disabling. Yet many seniors require intensive care during the final stages of their lives. Trying to address this challenge, a multi­ tude of attempts have been made over the past two decades to conceptualize and design alternative forms of elderly living beyond institutionalized care. Adult day­ care centers, independent and assisted housing options for aging-in-place, elderly co-housing and inter­genera­ tional projects are different concepts to innovate forms of elderly living in the future. They aim both at extending the stay in the first two categories of retirement housing and also, partly, at substituting the third. These attempts illustrate the hope that institutional care, in the long run, could be abolished and substituted by radically new models of elderly care. I do not entirely subscribe to this point of view, for two reasons.

First, if we look at the sheer numbers, in most Western countries ten to fifteen percent of all elderly live in nursing homes, and the overall need for long-term care is projected to double by 2050. In other parts of the world, there is an immense growth potential. China, for example, is facing an accelerated growth of its aging population, and the typical family tree is made up of one child that has to look after two aging parents, and four aging grandparents. This so-called ‘1-2-4’ family is a result of China’s one-child policy. This makes it un­ mis­takably clear that despite all the attempts to sub­sti­ tute inpatient-nursing facilities, there will be institutional nursing homes in decades to come. Just like housing blocks will not disappear due to innovations in villa design, nursing homes will also remain the place for terminal care for a majority of people in the industrialized world.

Second, within the discipline of architecture, there are usually two fundamental models in order to implement change when facing a typology’s difficulty to perform sufficiently. There is one that promotes revolutionary change and radical typological reinvention, and there is another that pursues a more evolutionary model of change and transformation. This is not an either/or choice, however. Both avenues can and should be pur­ sued simultaneously. Focussing on retirement housing, this means that in addition to designing new solutions, we may as well try to transform the known types into more enabling environments by strategic adjustment.

The search for new forms of living for the elderly has already attracted a lot of attention, such as Arons en Gelauff’s stealthcare projects. In contrast, the skilled nursing facility is in a rather outdated state in terms of architectural performance. Against this background, I advocate focusing the search for strategic adjustments on the nursing home, instead of turning a blind eye towards a very common type of retirement housing.

My aim, therefore, is to look into how we could cope with the specific difficulties of the skilled nursing facility by examining the brief; identifying the actors and conflicting interests involved; and by projecting the

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designer’s contribution in negotiating the divergent de­ mands of the owner, the operator and the user. How can we re-imagine the typology of the ‘skilled nursing facility’?

Volume 27

The Brief and the Actors

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One usually enters a skilled nursing facility in the terminal stage of life. And it is typically the place where, once entered, one will pass away. At best, it will become the final home. The length of stay commonly does not exceed three years. Accordingly, these places are, often due to functional requirements, hospital-like infrastructures with highly regulated and standardized environments.

They tend to be very repetitive by nature, and leave little space for privacy, collective interaction, sensual stimu­ lation, and ultimately self-determination.

The project briefs for new nursing homes are produced by a multitude of actors with different, often competing, if not at times contradictory agendas. There is the client who is either profit-oriented (if private) or holding a social mandate (if public); there is the operator and its care personnel who pursue smooth operation and efficiency; and finally there is the elderly inhabitant with the desire to spend the remaining years in dignity and well-being as much as possible. While all three interests should shape the brief, often one prevails over the others.

Traditionally, it is biased to support staff convenience, efficiency and safety, rather than to consider the daily life from the individual perspective. In practice, nursing home briefs are often complemented by detailed and highly regulated technical programmatic requirements that are almost manual-like. If one browses, for example, the State of Lower-Austria’s standard brief for newly built nursing homes, many pages are devoted to fire safety, energy efficiency, the plumbing systems’ resist­ ancy against the proliferation of infectious bacteria, and wall and corner protectors against wheelchair incidents.

While these concerns are undoubtedly relevant, there is little record of concrete requirements to support privacy, indi­viduality, interaction and communal spirit to unfold, and only limited mention of outdoor and common spaces and their stimulative qualities is made.

If it comes to the desires of the ultimate user, the nursing home should facilitate individual expression and privacy, help prevent the complete loss of inde­pen­ dence, and enable interaction with non-residents. Strong sensual stimulants, both inside and outside, function as compensation for disability and loss of independence.

Ultimately, the residents’ disabled daily life asks for a maximum of enabling qualities that could be performed by the architecture, to make the new environment feel like an enjoyable last home for those elderly who require intensive care.

Operators of nursing homes and their care personnel, on the other hand, have a slightly different agenda. Although they do share with inpatients the aim for their utmost well-being, it is maximized super­vision, streamlined care operations, sanitized materiality, and collective and passive activities that dominate their requirements for spatial performance. If one were to entirely let these guide the nursing home brief, one would arrive at a figurative Foucaultian panopticon organizing daily life. A further aspect to the caretaker’s agenda in the brief is an emphasis on standardization and rationa­li­zation in regards to the operational capacity of space for healthcare and hygiene. This largely results in a general lack of individuality and difference.

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The Nursing Home Designer as Mediator

To the designers, the various protagonists create a challenge. They have to try to find strategies that can turn the most repetitive and standardized, the most regulated and determined program into something that caters to individuality, appropriation by the user, com­ munity, interaction and sensual stimulation – yet without compromising the need for orientation and ergonomics, security and sustainability. How can one instil, at least, phenomenal difference that can make space for some individuality and privacy, some stimulation and inter­ac­ tion, and that can ultimately recreate a notion of home?

Very often, despite good intentions, the attempt to recreate an idea of home in nursing facilities merely illustrates its difficulty because of its actualizations through symbolic and superficial representation: the style of furniture, the choice of material finishes, the co­ ziness of false fireplaces or other interventions that only create a simulacrum, thereby underestimating the actual psychological dimension of home. According to Joelle Bahloul, the notion of home is closely linked to memory, and domestic memory relies not only on images of place but more importantly on images of concrete and im­me­ diate acts. So we must mediate the conflicting interests in the brief and transform the typology in such a way that we can allow for these images of acts to build up.

While the private room as described in the brief is the most constrained and fixed area, the room’s boundaries, as well as the common and shared spaces, offer some leverage to structure memory through the conditioning of space for personal and inter-personal acts to occur.

Although many people fear to end their lives as inpatients, new nursing homes are commissioned every day. Rather than turning a blind eye to this reality, or merely providing a submissive, brief-based service, archi­ tects should aim to stretch, transform and ultimately redefine the brief. In this way, architects can extend the current limits of performance, and go beyond commonly accepted boundaries – and in the best of cases, build up a series of acts in order to create a sense of home.

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Nursing Ho me Hainburg, Austria Architecture Christian Kronaus + Erhard An-He Kinzelbach Collaborators S. Gruber, D. Lopez The refurbishment and extension of this nursing home (2009) was taken as an opportunity to add individuality to a building type that is characterized by wards and hospital-like conditions. The repetitive rationality that comes with the brief is softened and adjusted to allow for differentiation.

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Upper floor plan

Legend 0 Cafe courtyard

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2 Therapy garden

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Lower floor plan

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13 Seminar room

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Photo T. Ott

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Photo T. Ott

In this project, the nursing home’s facade enables engagement of the phys­i­cally im­paired with the environment through dif­f er­ent parapet heights. It also fosters indivi­duality by marking the rooms outside and by pro­viding integrated, personal flower planters.

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Photo EA. Kinzelbach

Volume 27

In typical nursing homes, both indoor and outdoor common areas are consolidated. In Hainburg they are dispersed and designed to facilitate social interaction and personal recreation. Various balconies and terraces as well as wheel chair-accessible, elevated planters constitute stimulating environments.

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